Winkelmann's Procedure for Hydrocele Treatment
Winkelmann's procedure is an effective surgical technique for treating hydrocele that involves resection of the tunica vaginalis with eversion and suturing behind the testis to prevent recurrence.
Definition and Technique
- Winkelmann's procedure is a surgical approach for treating hydrocele that involves making an incision in the scrotum, draining the fluid, excising most of the parietal layer of the tunica vaginalis, and then everting and suturing the remaining edges behind the testis 1.
- The procedure aims to prevent recurrence by eliminating the potential space where fluid can accumulate 1.
Indications
- Symptomatic hydrocele causing discomfort, pain, or cosmetic concerns 1.
- Large or multilocular hydroceles that are unlikely to respond to less invasive treatments 2.
- Cases where sclerotherapy has failed or is contraindicated 3, 2.
Efficacy and Outcomes
- Studies show Winkelmann's procedure has a high success rate with approximately 61.45% of hydrocele cases being treated with this technique in some clinical settings 1.
- The procedure provides definitive treatment with low recurrence rates when properly performed 1.
- Postoperative hospital stay averages 8.6 ± 1.2 days according to some studies, though this may vary based on surgical technique and complications 2.
Potential Complications
- Common complications include scrotal edema, hematoma, and wound infection 2.
- Rare complications may include testicular blood vessel compression requiring reoperation (reported in 0.52% of cases) 1.
- Wound suppuration has been reported in approximately 1.02% of cases 1.
Alternative Procedures
- Bergmann's procedure is another common surgical approach (used in 32.81% of cases in one study), which involves removal of the parietal layer of the tunica vaginalis without eversion 1.
- Lord's procedure is a simpler technique that avoids isolation of the hydrocele sac from adjacent tissues and may result in shorter hospital stays (3.4 ± 0.6 days) 2.
- Aspiration and sclerotherapy with agents like doxycycline or tetracycline can be considered as non-surgical alternatives with success rates of up to 84% after a single treatment 3, 2.
Anesthesia Considerations
- The procedure can be performed under local anesthesia with sedation, avoiding the morbidity of more aggressive anesthetic techniques 4.
- Local anesthesia typically involves injecting the spermatic cord and scrotal wall with 2% mepivacaine (10-20 cc) 4.
- Monitored anesthesia care with EKG, blood pressure, and pulse oximetry monitoring is recommended 4.
Modern Approaches
- Endoscopic hydrocele ablation is an emerging minimally invasive alternative that allows visual inspection of scrotal contents with minimal manipulation 5.
- Endoscopic approaches may result in less postoperative discomfort and faster recovery (average 2 days) compared to traditional open procedures 5.
Recommendations for Clinical Practice
- Resection of the covering sheets of the testis is recommended as a prophylactic measure against recurrence 1.
- Patient selection should consider factors such as hydrocele size, complexity (multilocular vs. simple), and patient comorbidities 2.
- For patients who are poor surgical candidates, aspiration and sclerotherapy may be considered as a less invasive alternative 3.